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Medical Travel Refund Request
Medical Travel Refund Request Form
OMB: 1240-0056
IC ID: 224888
OMB.report
DOL/OWCP
OMB 1240-0056
ICR 201612-1240-006
IC 224888
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Medical Travel Refund Request
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 30.404
20 CFR 725.406
20 CFR 10.315
20 CFR 725.701
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
342,452
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
342,452
0
0
342,452
0
0
Annual IC Time Burden (Hours)
56,849
0
0
56,849
0
0
Annual IC Cost Burden (Dollars)
171,123
0
0
171,123
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.